Literature Review 

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THE 2003 WESTERN EUROPEAN HEAT WAVE

MAUREEN DONNELLEY, CAITLIN KELLY, SCOTT MICKALONIS, ANDREW VERDERAME

MILLERSVILLE UNIVERSITY OF PENNSYLVANIA

The summer heat wave that affected much of Western Europe in 2003 caused many to question whether steps could have been taken to mitigate the high mortality rates that were observed during the heat wave in many countries, especially in France.  In order to investigate this matter further, a review of literature concerning this event was performed.  The purpose of this literature review was to explorethe various ways that the Heat Wave impacted the Western European population.

Physical Impacts

The physical impact section examines the consequences and immediate effects of the heat wave striking Western Europe in the summer of 2003.  Physical impacts include mortality, morbidity, as well as economic losses.  France was the country that experienced the greatest increase in mortality due to the 2003 heat wave.  During the summer of 2003 mortality rose in France by 60% when compared to the average values observed for the same interval in the 1999–2002 period.  During that period 14,802 people died due to heat related causes (Fouillet, et al., 2006).  In the case of Spain, increased mortality stood at around 6,500 deaths more than expected, based on the modeling that was done for the baseline 1990–2002 period (Martinez et al., 2004).  Portugal experienced similarly effects with a 43% increase (based on the mean for the 2000–2001 period) or 1,953 persons.  It was reported that 3,134 excess deaths occurred in Italy during the heat wave (Kovats et al., 2004; Michelozzi et al., 2005).  In England and Wales, there were around 2,139 (16%) excess deaths directly related to the heat wave.  Reports elsewhere indicate that approximately 7,000 heat related deaths occurred in Germany, 1,250 deaths occurred in Belgium and 1,410 persons in Baden-Wurttemberg (Herrera, et al., 2010).

Although characteristics of the heat wave affecting Western Europe’s population vary with each country, the existence of common patterns is nonetheless evident.  During the 2003 European heat wave the greatest impact in terms of mortality and morbidity was in specific vulnerable populations more susceptible to the effect of heat.  These vulnerable populations are represented by people with impaired physiological and behavioral responses to heat due to their old age (Johnson, 2005), to the presence of chronic illnesses (Michelozzi, et al., 2006), to limited social contacts (Vandentorren, et al., 2006), to living alone (Canoui-Poitrine, et al., 2005), to low socio-economic conditions (Stafoggia, et al., 2006) and limited access to air conditioning (Vandentorren, et al., 2006).

All reports demonstrate that the mortality impact of the 2003 heat wave was greatest on the elderly.   In France excess mortality was estimated at 20% for those aged 45-74 years, at 70% for the 75-94 year age group, and at 120% for people over 94 years (Pirard, et al., 2005).  The heat wave had a major effect on mortality in England and Wales as well, but not to the extent of that observed in France (Kovats, et al., 2004).  Overall, there were 2139 (16%) excess deaths in England and Wales.  Once again the worst affected were people over the age of 75 years.  Mortality in people over the age of 75 increased by 22%, significantly more than the increase seen for other age groups, 11% for the 0-64 age group and 3% for the 65-74 age group (Johnson, et al., 2005).  A total of 2399 excessive deaths were estimated in Portugal, and these deaths were also observed in the older age groups, mainly 75 years old and above (Nogueira, et al., 2005).  Furthermore, in Spain significant excess mortality was observed only in the elderly, 75 years and older, while among those 64 years and younger, mortality actually decreased during the heat wave (Simon, et al., 2005).  When subdividing by age group, excess mortality increased dramatically with age in Italy.  The greatest impact was observed in the old (75-84 years) and the very old (85+ years) age groups with over 4000 excess deaths reported, a 14% increase (Michelozzi, et al., 2005).  Finally in the Netherlands, between 1400 and 2200 deaths were related to the heat wave in the summer of 2003.  With heat related mortality being the most pronounced among the elderly in nursing homes (Garssen, et al., 2005). 

During the 2003 heat wave four countries stratified deaths by sex.  Among the elderly in France, Spain, Portugal and Italy mortality rates were much higher in females than in males (Michelozzi, et al., 2005; Fouillet, et al., 2006; Conti, et al., 2007).  In France mortality rates were 15% higher in women than in men when equal ages are considered, from age 55 years.  However the overall excess mortality for women was 75% higher than that for men (Fouillet, et al., 2006).  The number of excess deaths estimated for women in Portugal was more than twice the number estimated for men, it was observed that mortality in women increased 79%, which was considerably higher than the 41% recorded for men (Conti, et al., 2007).  Moreover, in Italy the greatest increase in mortality also occurred among females with an estimated daily excess mortality rate of 35% (Michelozzi, et al., 2005).  As in the case of the previously stated countries, the largest excess mortality was also observed for women over the age of 65 years in Spain (Herrera, et al., 2010).

Although an increase among women was observed in all educational groups, in some countries the increase was larger for people with less than primary education.  In Italy and Spain the excess number of deaths was higher for those with a lower socio-economic class and less education.  Vulnerable groups, such as the elderly, those with lower socioeconomic status and people with minimal education, often remain in cities where a heat wave would be its most extreme due to the urban heat island. Several other socioeconomic factors played a role in Europe’s increased mortality rate, including poor housing quality, lack of air conditioning, lack of access to health and lack to social services.  Furthermore it was found that when elderly people live alone, they may not receive adequate care during a heat wave and are also unlikely to call for medical attention.  This was shown in France found as loss of independence and social isolation played a major role in mortality rates among the elderly (Fouillet, et al., 2006). 

The economic losses associated to the 2003 European heat wave have been estimated as exceeding US$ 10 billion, with more than 1billion Euros due to forest fires in Portugal (Munich, et al., 2004).  Other sources estimate losses of 13.1 billion Euros due to forest fires and drought in the European Union (COPA-COGECA, 2003).  These estimations included life insurance payments for heat wave and wildfire deaths; property damage and direct health costs, including hospital stays, clinic treatments, and ambulance rides; livestock and crop damages; fire and timber losses; and hydroelectric power restrictions.  Furthermore, electricity prices rose above 100 Euros/MWh (Fink, et al., 2004), and most of the French nuclear power plants suffered from overheating, which lead to interruptions of power. 

Psychological Impacts

This section examines the work on the emotional stress, trauma and other psychological impacts of the 2003 European heat wave.  Research on this area is limited, yet psychological consequences of the 2003 heat wave were observed in several European countries.  During the heat wave, 125 psychiatric emergencies were attended to in Barcelona, Spain.  This amount accounted for 14 percent of the total psychiatric emergencies attended to during the entire summer (Bulbena, et al., 2006).  In France the percentage of patients admitted to the psychiatric department was substantially higher in 2003 compared to 2002: 32.1% in 2003 compared with 15.4% in 2002.  However suicidal behavior was significantly less prevalent during the heat wave compared to 2002: 12.3% of the patients were diagnosed with suicidal behavior in 2003 compared with 25% in 2002 (Morali, et al., 2007).  During the heart wave, significantly more alcohol and sedative use disorders were reported in Spain, and patients were less likely to report anxiety disorders.  In addition individuals seen during the heat wave were more likely to report a history of psychiatric conditions and treatment and greater use of psychiatric services; they also had to be restrained more often and had higher scores on the SPI scale item measuring dangerousness toward others (Bulbena, et al., 2006).

Impact on Urban Population Centers

            The term “heat island” is used to describe the phenomena where condensed urban areas are hotter than nearby rural areas (Haines, et al., 2006).  The annual mean air temperature of a city with 1 million people or more can be 1.8–5.4°F (1–3°C) warmer than its surroundings. In the evening, the difference can be as high as 22°F (12°C). Heat islands can affect communities by increasing summertime peak energy demand, air conditioning costs, air pollution and ozone levels, heat-related illness and mortality, and water quality.  The Western European Heat Wave of 2003 presented a special problem in urban areas because buildings retain heat at night if ventilation is inadequate (Hoffmann, et al., 2008).  Air pollution, which is usually worse in urban areas than rural areas, can also exacerbate the health-damaging effects of high temperatures on the people living in urban areas (Larsen, 2003; Haines, et al., 2006).  A review of literature on the Western European Heat Wave of 2003 shows that mortality rates were quite high in urban areas, primarily in France.

            While investigating the relationship between temperature, ozone, and mortality in nine French cities during the 2003 heat wave (Filleul, et al., 2006), it was learned that high levels of ozone commonly found in larger cities did contribute to increased mortality rates during the heat wave, with the exception being the city of Lyon.  Although Lyon had the 4^th largest population of all of the cities studied, a positive association between an increased level of ozone and mortality was not shown (Filleul, et al., 2006).  No possible explanation for this phenomenon was provided.

            Another study examined the mortality in 13 French cities during the August 2003 Western European Heat Wave.  This research concluded that the high mortality rates in France during the record-breaking heat wave were impacted by size of the city and the urban heat island effect (Vandentorren, et al., 2004).  The study also showed that the geographical location of the particular city had an effect on mortality rates.  Cities located in the central and eastern regions of France where the residents were not accustomed to such high temperatures saw higher mortality rates compared to cities located in the Southern part of France (Vandentorren, et al., 2004).

            Residing in an urban environment, when combined with advanced age and gender differences, was part of the focus by Poumadere, et al. (2005) when an analysis of the 2003 French Heat Wave attempted to shed light on how heat wave dangers result from the intricate association of natural and social factors.  This study also highlighted an epidemiological study that was conducted by the Health Monitoring Institute in 9 large French cities that estimated 379 deaths were attributable to high concentrations of ozone during the heat wave (Poumadere, et al., 2005).

Impact on Rural Population Centers

            Studies that have been published which have examined the effects of the 2003 Western European Heat Wave on urban populations greatly outnumber the number of publications that examine the effects of the heat wave on rural populations.  The exception is the work performed by Hoffmann, et al. (2008) which studied the increased cause-specific mortality that was associated with the 2003 heat wave in Essen, Germany as compared to a rural area.  Although Essen is a large industrial city with a population of almost 600,000 people, it is located in the same region as the other focus of the study, the small rural district of Siegen-Wittgenstein.  The study only revealed a minor association between the two areas regarding total mortality levels during the heat wave, but the duration of the heat wave was much shorter and night temperatures were much lower in Siegen-Wittgenstein (Hoffmann, et al., 2008).  This was mainly attributed to the forest and grass covered terrain primarily found in the region, unlike the local urban areas such as Essen and Frankfurt.

            The shortage of studies that focus on rural areas during the heat wave has been recognized by Josseran, et al. (2009) while studying the heat wave and its effects on hospital emergency departments in France.  The authors acknowledge that the study was limited to large cities and is therefore, not representative of the French population as a whole.  According to Josseran, et al. (2009), “For other areas (i.e., rural area), the impact of heat wave on population could be different and complementary analysis should be necessary” (p.7).

            It is obvious that most scholars who studied the 2003 Western European Heat Wave chose to study its effects on urban areas, possibly due to the fact that mortality rates were reported to be higher in urban areas and previous research on the subject would be more plentiful as compared to studies on rural populations. 

Public and Environmental Health Impact

            The heat wave that affected most of the European countries during 2003 was the most severe ever in recorded history. In terms of mortality and environmental impact, the 2003 heat wave was devastating. The sultry weather came about because of an anti-cyclone that fixed itself over Western Europe (DeBono, 2004, p.1).  This resulted in a 20-30 % increase in temperature across the region.

DeBono et. al (2004), reports an impact to the environment that is widespread. There was a noticeable increase in wildfires because of the drought. The ice cap on the European Alps experienced above normal temperatures for an extended period of time causing a significant decrease in glacier thickness. Crop harvest was affected by a warmer than normal summer and a lower rain amounts.  The ensuing drought scorched vegetation and caused millions of dollars in lost revenue to various European agriculture centers.

            The World Health Organization (WHO) reports that these temperature increases and environmental changes had been ongoing for some time. An average of 0.3 degrees C rise in temperature yearly over the past decade had been identified (WHO-Europe, 2003, p. 2). The rapid increase in temperature over the period has been identified but its causes are not yet known. Increases in the frequency of sustained warm weather days, not previously reported, were also noted. WHO-Europe identifies a concern that these sustained warm weather events are going to become even more frequent and intense as time progresses and the climate changes.

            The resulting environmental factors that have been described had a substantial impact on the health and welfare of people throughout Europe.  The loss of agricultural production capability and the wildfires that raged across dry vegetation caused had both nutritional and respiratory health impacts on the public. These issues were seen the most in the elderly and others of particular special need. These individuals were seen as particularly vulnerable to the risks associated with the heat wave.  As a result of these vulnerabilities, nearly 35,000 people died as a direct result of the 2003 heat wave (Bhattacharya, 2003, p. 1). Heat waves are considered a “silent killer” in elderly populations, as the deadly effects of them is not given the importance they require.

            As researched, the most influential public health impact related to the heat wave of 2003 was a lack of a substantial warning system for heat related emergencies. Only two European nations had hot weather warning systems in place at the time of the 2003 emergency. Hot weather warning systems are important to the social populations that are affected by extreme heat. These warning systems are designed to help people prepare for these extreme conditions. Social factors that are of extreme risk include the elderly, particularly those who live alone, without air conditioning or on top floor apartment buildings in urban areas (Kovats, 2006, p. 592). It is described that these vulnerabilities to extreme heat led to a significant increase in deaths, across all of Europe.

            Bernard (2004) suggests that a plan must be put into place to be able to prepare for and respond to heat emergencies. These include: 1) defining a specific lead agency. 2) Utilization of a concise warning system. 3) Communication and public education programs. 4) Identification of special needs populations and responding to them as necessary. 5)  Evaluation of information received and 6) Revision of the plan. The review of this document stresses the need for municipalities to have a plan and place and set forth a response to an event based on the plan.  This is due to heat related deaths having become the highest risk for fatality than any other weather event (Bernard, 2004, p. 1520).

            The plan set forth for heat emergencies have been reportedly led by public safety agencies, emergency managers and health departments. Each of these agencies plays a vital role in the response to heat emergencies. However, cities in Europe and North America have traditionally failed to follow the necessary steps to assist at-risk populations.

            Criteria have been established to effectively put into place a comprehensive heat health warning system. Kovats (2006) suggests that emergency managers review objectives for the program prior to instituting a warning system.  The objectives would include threshold values for starting and ending the warnings, monitoring, lead time on warnings and targeted populations. The goal is to conduct the necessary research on the risk and vulnerability and develop a warning system.  Once a system has been determined, a cost/ benefit analysis should be conducted to determine the viability of the program.  Finally, the system should be reviewed and evaluated on a set of criteria to ensure that people have access to it, is simple and easy to use and provides the necessary information that is needed for citizens to respond appropriately for their protection.

            Specifically, in the case of the 2003 European heat wave, there were few reliable hot weather warning systems in place to conduct necessary notification. Since the disaster, many nations including, France, Italy, Spain, England and Portugal have instituted varying plans. They include city level warning notifications, vulnerable population identification, country-wide warning systems, mortality tracking and voluntary registration of high-risk persons (Kovats, 2006, p. 594).

            With the institution of these warning systems, European nations began their recovery and mitigation strategy for heat related events.  According to Kovats (2006), the heat wave plan was initiated at various levels across varying nations. Leaflets and voice notification systems, public service announcement, public outreach programs and cooling center establishment have all been methods utilized across Europe to react to extreme heat emergencies. It was found though, that although cooling centers were established and planned, very few people referred these locations. Though more expensive, Kovats describes the utilization of home visits that have proven to be successful. Additionally, the distribution of fans and outreach to homeless populations has been found to be successful to reduce the chance of mortality.

            The 2003 European Heat wave had several public health effects including biological and environmental. The social effects on the people in Europe ultimately caused the deaths of 35,000 people across several nations. Vegetation and crop loss resulted in economic loss and affected the public health and welfare. The lack of a substantial heat health warning system across the European nations ultimately caused a lack of planning and decreased response to the people in need. Since that time, nations who were affected by the heat wave have introduced heat health warning plans based on threshold values, resources and evaluation criteria.  It can be assumed that heat waves will continue to be the leading cause of fatality among weather related disasters and reviewing literature of past events can help to plan for the future.

Politics of Heat Waves

            Although extremely deadly, heat waves tend to be ignored by the pubic and in the press because of their seeming alignment with typical temperatures and their most common victims – the elderly, who are often considered to have died from natural causes, at least until the death toll gets unreasonably high. Heat waves offer no dramatic weather-caused destruction to capture for the news, and in fact, it is not even entirely clear when discomfort becomes dangerous. The 2003 heat wave was the worst natural disaster in Europe in 50 years (De Bono, et. al., 2004), yet the public awareness of its severity was minimal throughout, and the government response was very delayed. That year, Western Europe saw unusually warm temperatures beginning in June, and by the middle of August, rising heat would claim the lives of  over 52,000 people, approximately 15,000 of which were in France alone (Larsen, 2006).

The realization of the heat’s affect on its citizenry served as a lesson for many governments. With no rapid onset of devastation, there is no clear trigger on when to begin a response, and it seems that governments of affected countries took a wait-and-see approach, hoping for the best, and not worrying seriously about mortality.

            Much of the research draws comparisons between the 2003 European heat wave and the 1995 Chicago heat wave, and in particular, reference Eric Klinenberg’s book, Heat Wave, which discusses the social and political aspect of the Chicago event (see Ho, 2004; Kysely and Kriz, 2008; Langer, 2004; Lagadec, 2004; Thirion et al, 2005). Had his research been widely known, most of the problems could have been avoided, and many lives could have been saved. The following quote that Klinenberg wrote in reference to Chicago seems to also sum up the experience in Europe:

“When…people die slowly, alone and at home unprotected by friends and family and unassisted by the state, it is a sign of social breakdown which communities, neighborhoods, networks, governmental agencies, and the media charged with signaling warnings, are all implicated” (Klinenberg, 2003, p. 32).

Before the 2003 event, only two European cities had comprehensive heat health warning systems in place; Rome and Lisbon (WHO, 2003).

Some countries began reacting to the heat wave and its secondary effects in early August during the hottest days. German officials weighed the benefits of letting citizens leave work early to retreat to cool, less stressful environments. In Portugal, firefighters worked to snuff wildfires that destroyed over 100,000 acres of woodland, and its citizens as well as some Spaniards were evacuated out of the fires’ paths. Britain canceled trains and imposed slower speed limits on some busy routs to prevent rails from buckling, and Italy had crop shortages and irrigation problems due to the drought (Bruni, 2003). However, none seemed to realize just how dire the situation was becoming. France had the highest mortality rate, and the most negative reaction to the government’s actions (or inaction), so is the focus of this discussion on political response.

Having ignored elevated temperatures throughout the summer, during the first week of August, heat-related health issues in France were finally undeniable and the government began to prepare public statements, including warnings to the elderly in particular (Lagadec, 2004). France is not used to extremely hot summers, and air conditioning is not widely used (Vandentorren, et al, 2004), so the heat was inescapable for many French citizens. The heat could not have come at a worse time of year, as August is known to be the vacation month in France. Many people had left their elderly relatives behind, businesses often shut down, hospitals were understaffed and as Ho (2004) notes, even the government was on vacation. The directors’ absence impeded a response and mobilization.

Early warnings from scientists were seen as exaggerated statements on unfounded risk, and the reporting of deaths did not cite heat as a cause initially. Furthermore, the country was dealing with forest fires, railway problems, high pollution levels, legionella-epidemics and nuclear plant problems. The heat wave response seemed less urgent (Lagadec, 2004).

The French National Health Surveillance Agency recognized the need for a survey on Friday, August 8, but put it off until after the weekend, and began on Monday, August 11. That weekend proved to be a very deadly one. On August 11, the Ministry of Health gave a television address aimed at reassuring the public (Lagadec, 2004). Lagadec, a French researcher in Paris, writes that the government initially did not take responsibility for the dramatic effects of the heat on the public, and hinted, as occurred in the Chicago heat wave of 1995, that guidance was offered, but ultimately the public was responsible for its own care. The initial response was to “deflect and defend,” claiming officials were not informed of a problem, that the event was unprecedented, that nothing could have been done, that the elderly victims would have died anyway and families should be responsible for their older relatives’ care. “The minister of health even criticized his own services for their poor response, which led to the resignation of the General Director of Health, and international leading expert in epidemiology” (Lagadec, 2004, p. 161).  However, a New York Times article written within a month of the heat wave’s conclusion noted: “Like Chicago officials in 1995, the French government was slow to react to the heat crisis. But the similarity ends there. France has taken up the problem as a social and political issue” (Brock, 2003). Ho (2004) writes that the public blamed neither the health care system nor the government.

It was not until August 14 – which would be the last day of the heat wave – that a national reaction was ordered in the form of the mobilization of hospitals (Lagadec, 2004). France had “no central coordination for warnings or emergency response tactics from Paris,” nor did they have a financial or social plan for handling the increased cost of emergency service (Ho, 2004, p. 30).

Lagadec (2004) cites a heavily administrative culture (not unique to France) as a major impediment to a quick and successful response.

“Bureaucracies are organized and trained to work on stable data, formatted problems. …established rules…and a programmed time frame. This culture is so prevalent that it permeates monitoring, even when obviously incompatible with the task at hand and its time frame” (p. 162).

Ho also notes bureaucracy as a cause to the high mortality rates in France, as well as the “shocking lack of public health education and awareness initiatives” (2004, p. 31). However, he believes “the real problem is sociological. The population is steadily getting older … and the elderly are living alone and dying alone” (Lagadec, 2004, p. 31).

Following the summer of 2003, France’s Directorate General for Health (a position heavily criticized for the response, leading to a resignation) worked with the Ministry of Health and the Directorate General for Civil Defence and Security to create the National Heat Wave Plan. “The plan includes several measures: set-up of a system for real-time surveillance of health data, compilation of scientific recommendations on the prevention and treatment of heat-related diseases, air-conditioning equipment for hospitals and retirement homes, drawing up of emergency plans for retirement homes, city-scale censuses of the isolated and vulnerable, visits to those people during the alert periods, and set-up of a warning system” (Fouillet, et. al., 2008). In addition, the plan includes funding to increase the number of hospital beds and health care workers (Larsen, 2006).

Since the 2003 heat waves, much more attention has been given to heat warning plans, and government are more reactive during the early stages of the onset of heat. The weather is reported with warnings on the dangers associated with prolonged exposure to heat, especially among the elderly. In Spain, for example, “the government’s heat wave action plan includes and awareness campaign for social service and health care professionals, a voluntary register for people at high risk to receive special services, and a daily mortality monitoring system” (Larsen, 2006). Instead of risking another devastating – and preventable – disaster, governments are taking a more cautious approach toward heat waves.

So while only two cities (Rome and Lisbon) had heat wave plans in place before the 2003 event, most of the Western European countries created plans following the disaster. The World Health Organisation Regional Office for Europe has a web site with links to such plans for Belgium, Denmark, France, Germany, Italy, Luxemburg, the Netherlands, Portugal, Spain, Switzerland, and the United Kingdom (www.euro.who.int). However, research from the Earth Policy Institute states that the 2003 heat wave did not get the media attention it warranted, in part because reports of casualties “trickled out of individual countries over more than two years following the actual event” (Larsen, 2006). This meant that neither policymakers nor the public fully grasped the severity of the event and as a result, they still underestimate the risk of rising temperatures.

Nevertheless, improvements have been apparent. According to Kysely and Kriz (2008), mortality rates have decreased in heat waves since the 2003 event, at least partly due to improvements in general health, medical-technological changes, and more widespread use of air conditioning. They also note that since 2003, there is greater public awareness of the dangers of heat waves. Further, more reliable forecasts coupled with heat-related warnings have also changed the public perception of heat (Kysely & Kriz, 2008).

            Fouillet, et al. (2008) studied a 2006 heat wave in France, comparing it to the disastrous 2003 heat wave. They note that in 2003, governments showed an “overall lack of reactivity”. However, since then, France and other parts of Western Europe’s response have proven more proactive. For example, in July, 2006, when temperatures moved well above average, French authorities declared an orange alert, signifying a ‘dangerous weather phenomenon’ (the second highest level). “The alert prompted a nationwide bulletin urging vigilance of at-risk people, especially the elderly, children and the handicapped” (Soriano, 2006). Italy open air-conditioned shelters in Milan and Rome, and Britain declared a ‘Level 3 Heat Wave’ – also one step below the highest alert level – which “requires doctors and local authorities to maintain daily contact with at-risk people who live alone” (Soriano, 2006).

It is known who needs services, who suffers the most, and who actually seeks out services during heat waves (Langer, 2004), and it is known how to prevent heat related deaths. With this combination, there is work to be done in normal times to save lives during extreme heat. Unfortunately, it seems that cities or countries need to experience the disaster before recognizing the seriousness and implementing emergency plans for heat waves.

                                                                  References

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            Bhattacharya, S. (October 10, 2003) European Heatwave caused 35,000 deaths. NewScientist. www.newscientist.com..

            Brock, F. (2003) Seniority; Victims of the Heat. Victims of Isolation. The New York Times, September 14, Sunday, Late Edition – Final.

            Bruni, F. (2003) Europe Sizzles and Suffers in a Summer of Merciless Heat. The New York Times. Wednesday, August 6, Late Edition – Final.

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            Josseran, L., Caillere, N., Brun-Ney, D., Rottner, J., Filleul, L., Brucker, G. & Astagneau, P. (2009) Syndromic surveillance and heat wave morbidity: a pilot study based on emergency departments in France. BMC Medical Informatics and Decision Making. 9 (14), 1-9.

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            Langer, N. (2004) Natural Disasters that Reveal Cracks in our Social Foundation. Educational Gerontology, vol. 30, pp 275-285.

            Larsen, J. (2006) Setting the Record Straight: More than 52,000 Europeans Died from Heat in Summer 2003. Earth Policy Institute, July 28.

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            Michelozzi P, de'Donato F, Bisanti L, Russo A, Cadum E, DeMaria M, D'Ovidio M, Costa G, Perucci, C.A. (2005) The impact of the summer 2003 heat waves on mortality in four Italian cities. Euro Surveill, 10:161-165.

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